Phila VA problems prompts oversight bill

Pennsylvania’s Democratic U.S. Senators Bob Casey and Arlen Specter introduced legislation Friday that would require the Department of Veterans Affairs to regularly report on the quality of care delivered at its hospitals.

The bill, which mirrors legislation introduced in the House of Representatives last November by Rep. John Adler (D., N.J.), would require the Veteran’s Health Administration to submit annual reports on programs that treat fewer than 100 patients a year in every VA medical center.

Former Philadelphia VA Medical Center director Richard S. Citron, who retired on April 30 after 42 years of government service.

The House and Senate bills were written in response to the problems in a prostate cancer program at the Philadelphia VA Medical Center. From February 2002 until it was shutdown in June 2008, the prostate brachytherapy program at the Philadelphia VA administered incorrect doses of radiation to 97 of 114 patients.

Prostate brachytherapy involves implanting dozens of tiny radioactive seeds into the acorn-size gland to kill cancerous cells over several months. It is an effective treatment when done correctly. Records show that the Philadelphia VA's program was deeply flawed from its earliest patients, and that doctors and officials repeatedly missed chances to fix it.

Earlier this year, the VA sought to retract 80 of 97 implants it had reported as medical errors, arguing that the quality of implants was within acceptable limits. The U.S. Nuclear Regulatory Commission, which oversees the medical use of radioactive materials, rejected that argument and imposed a fine of $227,500, which the VA paid in April.

On Monday May 3, the VA’s Inspector General’s Office issued a report on its investigation that found that when University of Pennsylvania doctors performed prostate cancer procedures at the Philadelphia VA, they made dozens of mistakes over six years, and investigators could find no evidence that anyone was providing oversight.

The inspector general’s report also found that no formal contract existed for many of those years between the VA and Penn. Instead, an interim 3-month contract was improperly renewed for years, and the VA ended up overpaying for Penn's services, the report concluded.

In addition to requiring reports on small programs such as the brachytherapy treatments in Philadelphia, The Veterans Health and Radiation Safety Act would require VA employees and contractors that work with radiation to be trained in what constitutes a reportable “medical event.”

Moreover, it would require contracts not be renewed without an independent evaluation of the contractor’s performance.

Check out the story published Tuesday’s in The Inquirer

Click here for the full IG report released at 4 p.m., Monday, May 3.

And check out earlier stories on the program at the Philadelphia VA:

Sunday, June 21, 2009
Feds see wider woes in VA's cancer errors

Sunday, July 19, 2009 
VA radiation errors laid to offline computer

Thursday, July 23, 2009
Federal official quantifies Phila. VA problems

Sunday, August 9, 2009
VA's prostate treatment woes began at Penn;
Prior to the VA program, leading brachytherapists said the Penn doctors performing the radioactive seed implants lacked the proper skills and safeguards.

Sunday, November 15, 2009
VA clinic troubles bring few penalties;
Despite poor care in the Phila. prostate program, the agency has only slapped a few hands

Wednesday, November 18, 2009
NRC cites VA clinic for radioactive-treatment violations

Wednesday, November 25, 2009
Claims against Phila. VA up to $58 million

Friday, December 18, 2009
VA apologizes but denies radiation violations

Saturday, January 16, 2010 
VA clinic now concedes violations

Thursday, Mar. 18, 2010
NRC fines Phila. VA $227,500 over prostate care